COVID-19 VACCINATION FOR PEOPLE WITH RHEUMATIC DISEASE - MARCH 2021 - Academy Medicine of Singapore
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MARCH 2021
CONSENSUS STATEMENT
COVID-19
VACCINATION
FOR PEOPLE WITH RHEUMATIC DISEASE
CHAPTER OF RHEUMATOLOGISTS
COLLEGE OF PHYSICIANS, SINGAPORE
ACADEMY OF MEDICINE CHAPTER OF RHEUMATOLOGISTS
SINGAPORE COLLEGE OF PHYSICIANS, SINGAPORE
BACKGROUND
It has been shown that people with rheumatic disease (PRD) may be more susceptible to adverse
outcomes from COVID-19, possibly due to the increased clustering of comorbidities among these
patients.1-3 The Health Sciences Authority (HSA) has approved the Pfizer-BioNTech® and
Moderna® COVID-19 mRNA vaccines via the Pandemic Special Access Route, and the Ministry
of Health, Singapore (MOH) Expert Committee on COVID-19 Vaccination (EC19V) has published
recommendations for their use.4 Other vaccines such as the Sinovac® vaccines will be evaluated
at a later date.5 So far, there is evidence that both the Pfizer-BioNTech® and Moderna® vaccines
are safe, immunogenic and efficacious; however, PRD on immunosuppression were excluded
from both the trials.6,7 In this consensus recommendation, the Chapter of Rheumatologists,
College of Physicians, Academy of Medicine, Singapore (henceforth called “the Chapter”) seeks
to address questions regarding the suitability of COVID-19 vaccination in PRD.
TARGET AUDIENCE
Healthcare professionals involved in the care of PRD.
METHODS
An expert panel was convened by the Chapter Chair. A core-working group reviewed the literature
and formulated draft recommendations for rating by an invited task force panel, which included
experts in adult and paediatric Rheumatology and Infectious Diseases. A modified Delphi
approach was used. Systematic literature reviews were performed to answer four research
questions (see below). Where appropriate, in lieu of a systematic review of the primary literature,
international best practice guidelines and recommendations of rheumatology societies on
vaccinations in PRD were reviewed. Other academic bodies’ recommendations for COVID-19
vaccination in PRD and / or immunocompromising conditions were also considered. GRADE
methodology for assigning level of evidence and strength of recommendations was used.8
GRADE system of assigning strength of recommendations:
• Strong: the desirable effects of an intervention clearly outweigh the undesirable effects, or
clearly do not.
• Weak (conditional): the trade-offs are less certain - either because of low quality evidence
or because evidence suggests that desirable and undesirable effects are closely
balanced.
PRD include, but are not limited to, those diagnosed with:
1. Chronic inflammatory arthritides (e.g. rheumatoid arthritis, psoriatic arthritis,
spondyloarthritides, juvenile idiopathic arthritis, adult onset stills disease)
2. Connective tissue diseases (e.g. systemic lupus erythematosus, immune mediated
inflammatory myositis, sjӧgrens syndrome, systemic sclerosis)
3. Primary systemic vasculitides
4. Autoinflammatory diseases
2Immunomodulatory drugs considered for this guidance include:
1. Conventional synthetic disease modifying anti-rheumatic drugs (DMARDs)
(methotrexate, sulphasalazine, leflunomide, hydroxychloroquine)
2. Biologic DMARDs (anti-tumour necrosis factor, tocilizumab, rituximab, abatacept,
secukinumab, ixekizumab, anakinra, belimumab)
3. Targeted synthetic DMARDs (tofacitinib, baricitinib, upadacitinib*)
4. Immunosuppressive drugs (cyclophosphamide, mycophenolate mofetil, azathioprine,
cyclosporin A, tacrolimus)
5. Glucocorticoids (any dose)
* not included in any of the searched literature on vaccines, hence recommendation is by
extrapolation
Research questions
1. Are PRD at increased risk of adverse outcomes from COVID-19?
2. Are existing approved vaccines against SARS CoV2 safe, immunogenic and efficacious
in PRD?
3. Are other (non-COVID-19) recommended non-live vaccines safe, immunogenic and
efficacious in PRD?
4. What is the effect of various drugs used in PRD on immunogenicity of (non-COVID-19)
vaccines in PRD?
It has been shown that PRD are more susceptible to adverse outcomes from COVID-19, possibly
due to the increased clustering of comorbidities among these patients.1-3 Extrapolating from
guidelines for other non-live vaccines in PRD, COVID-19 vaccination is likely to be safe. In
patients on immunomodulatory drugs, especially rituximab (RTX), high dose glucocorticoids
(>=20mg/day of prednisolone equivalent), methotrexate, and abatacept, there may be decreased
immunogenicity, and hence decreased efficacy.8-20
However, some degree of protective immunity is still likely to be achieved, other than with RTX,
where immunogenicity is significantly decreased if given within 6 months of the previous dose.21-
25
Antibody titres may not correlate with clinical efficacy, and the role of booster vaccination in
those with insufficient antibodies has not been established. Vaccination has not been associated
with flare of rheumatic disease; however, most studies were done in patients with quiescent
disease. mRNA vaccines are currently untested in PRD. Of note, nucleoside modification of
mRNA (for both Pfizer-BioNTech® and Moderna® mRNA vaccines) renders it unlikely to activate
the innate immune response, as suggested by in vitro studies.26,27
3REFERENCES
1. Xu CH et al. Clinical Outcomes of COVID-19 in Patients with Rheumatic Diseases: A
Systematic Review and Meta-Analysis of Global Data. Autoimmunity reviews 2021 (in
press).
2. Data from The COVID-19 Global Rheumatology Alliance Global Registry. https://rheum-
covid.org/updates/combined-data.html. Accessed on November 13th, 2020.
3. D’Silva KJA et al. COVID-19 Outcomes in Patients Living with Rheumatic Diseases.
American College of Rheumatology Convergence 2020.
4. MOH Recommendations on Singapore’s COVID-19 Vaccination Strategy By the Expert
Committee on COVID-19 Vaccination:
https://www.moh.gov.sg/docs/librariesprovider5/pressroom/annex-b-ec19v-27-dec.pdf
5. https://www.moh.gov.sg/news-highlights/details/ministerial-statement-by-mr-gan-kim-yong-
minister-for-health-at-parliament-on-the-third-update-on-whole-of-government-response-
to- covid-19. Accessed January 17, 2021.
6. Polack FP and Thomas SJ et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19
Vaccine. N Eng J Med 2020. DOI: 10.1056/NEJMoa2034577
7. Baden LR and El Sahly HM et al. Efficacy and Safety of the mRNA-1273 SARS-CoV-2
Vaccine. N Eng J Med 2020. DOI: 10.1056/NEJMoa2035389
8. Guyatt G et al. GRADE: an emerging consensus on rating quality of evidence and strength
of recommendations. BMJ 2008; 336: 924-926.
9. Rondaan C, et al. Efficacy, immunogenicity and safety of vaccination in adult patients with
autoimmune inflammatory rheumatic diseases: a systematic literature review for the 2019
update of EULAR recommendations. RMD Open 2019;5:e001035.
10. Furer V, et al. 2019 update of EULAR recommendations for vaccination in adult patients
with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis 2020; 79:39-52.
11. Seo YB, et al. The Practice Guideline for Vaccinating Korean Patients with Autoimmune
Inflammatory Rheumatic Disease. Infect Chemother 2020;52:252-280.
12. Guerrrini G, et al. Italian recommendations for influenza and pneumococcal vaccination in
adult patients with autoimmune rheumatic diseases. Clin Exp Rheumatol 2020;38:245-256.
13. Papp KA, et al. Vaccination Guidelines for Patients with Immune-mediated Disorders Taking
Immunosuppressive Therapies: Executive Summary. J Rheumatol 2019;46:751-754.
14. Holroyd CR, et al. The British Society for Rheumatology biologic DMARD safety guidelines
in inflammatory arthritis. Rheumatology (Oxford) 2019;58:e3-e42.
15. Keeling SO, et al. Canadian Rheumatology Association Recommendations for the
Assessment and Monitoring of Systemic Lupus Erythematosus. J Rheumatol
2018;45:1426- 1439.
16. Singh JA, et al. 2015 American College of Rheumatology Guideline for the Treatment of
Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2016;68:1-25.
417. Buhler et al. Vaccination recommendations for adult patients with autoimmune inflammatory
rheumatic diseases. Swiss Med Wkly. 2015;145:w14159
18. Rubin et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the
Immunocompromised Host. CID 2014:58
19. CDC. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal
Polysaccharide Vaccine for Adults with Immunocompromising Conditions:
Recommendations of the Advisory Committee on Immunization Practices (ACIP)MMWR
Morb Mortal Wkly Rep 2012;61:816-9.
20. Heijstek et al. EULAR recommendations for vaccination in paediatric patients with
rheumatic diseases Ann Rheum Dis 2011;70:1704–1712.
21. Oren S et al. Vaccination against influenza in patients with rheumatoid arthritis: the effect
of rituximab on the humoral response. Ann Rheum Dis 2008;67:937–41
22. van Assen S et al. Humoral responses after influenza vaccination are severely reduced in
patients with rheumatoid arthritis treated with rituximab. Arthritis Rheum 2010;62:75–81.
23. Gelinck LBS et al. Poor serological responses upon influenza vaccination in patients with
rheumatoid arthritis treated with rituximab. Ann Rheum Dis 2007;66:1402–3
24. Bingham CO et al. Immunization responses in rheumatoid arthritis patients treated with
rituximab: results from a controlled clinical trial. Arthritis Rheum 2010;62:64–74.
25. Crnkic Kapetanovic M et al. Rituximab and abatacept but not tocilizumab impair antibody
response to pneumococcal conjugate vaccine in patients with rheumatoid arthritis. Arthritis
Res Ther 2013;15
26. Karikó K, Buckstein M, Ni H, Weissman D. Suppression of RNA recognition by Toll-like
receptors: the impact of nucleoside modification and the evolutionary origin of RNA.
Immunity 2005; 23: 165-75.
27. Koski GK, Karikó K, Xu S, Weissman D, Cohen PA, Czerniecki BJ. Cutting edge: innate
immune system discriminates between RNA containing bacterial versus eukaryotic
structural features that prime for high-level IL-12 secretion by dendritic cells. J Immunol
2004; 172: 3989-93.
Links to other academic bodies’ guidance
1. European Alliance for Associations of Rheumatology (EULAR):
https://www.eular.org/eular_sars_cov_2_vaccination_rmd_patients.cfm
2. British Society of Rheumatology (BSR):
https://www.rheumatology.org.uk/practice- quality/covid-19-guidance
3. American College of Rheumatology (ACR):
https://www.rheumatology.org/Portals/0/Files/ACR-Information-Vaccination-Against-
SARS- CoV-2.pdf
4. Centres for Disease Control and Prevention (CDC):
https://www.cdc.gov/vaccines/covid- 19/info-by-product/clinical-considerations.html
5EXECUTIVE SUMMARY OF RECOMMENDATIONS
Overarching principles
1. Vaccination in people with rheumatic disease should be aligned with prevailing
national policy.
2. The decision for vaccination should be individualised, and should be explained to
the patient, to provide a basis for shared decision-making between the healthcare
provider and the patient.
Recommendations
1. We strongly recommend that eligible patients be vaccinated against SARS-CoV2.
2. We conditionally recommend that the COVID-19 vaccine be administered during
quiescent disease, if possible.
3. We conditionally recommend that immunomodulatory drugs, other than rituximab,
can be continued alongside vaccination against SARS-CoV2.
4. We conditionally recommend that the COVID-19 vaccine be administered prior to
commencing rituximab, if possible. For patients on rituximab, the vaccine should
be administered a minimum of 6 months after the last dose, and 4 weeks prior to
the next dose of rituximab.
5. We conditionally recommend that post-vaccination antibody titres against SARS-
CoV2 need not be measured.
6. We strongly recommend that household contacts be vaccinated against SARS-
CoV2.
7. We conditionally recommend that any of the approved COVID-19 vaccines may be
used, with no particular preference.
6ACKNOWLEDGEMENT
Core Working Group
(1) Dr Manjari Lahiri Chair, Chapter of Rheumatologists
Senior Consultant, Division of Rheumatology,
Department of Medicine
National University Hospital
(2) Dr Amelia Santosa Board Member, Chapter of Rheumatologists
Senior Consultant, Division of Rheumatology,
Department of Medicine
National University Hospital
(3) Dr Warren Fong Consultant
Department of Rheumatology & Immunology
Singapore General Hospital
(4) Dr Xu Chuanhui Senior Resident
Department of Rheumatology, Allergy & Immunology
Tan Tock Seng Hospital
Task Force Panel
(1) Dr Thaschawee Arkachaisri Head & Senior Consultant
Rheumatology and Immunology Service, Department
of Paediatric Subspecialties
KK Womens’ and Children’s Hospital
(2) Dr Kong Kok Ooi Head & Senior Consultant
Department of Rheumatology, Allergy & Immunology
Tan Tock Seng Hospital
(3) Dr Aisha Lateef Chief & Senior Consultant
Department of Medicine
Woodlands Health Campus
(4) Dr Lee Tau Hoong Vice Chair, Chapter of Infectious Disease Physicians
Consultant
National Centre for Infectious Disease
(5) Dr Leong Keng Hong Rheumatologist
Leong Keng Hong Arthritis and Medical Centre
(6) Dr Andrea Low Head & Senior Consultant
Department of Rheumatology & Immunology
Singapore General Hospital
(7) Dr Melonie Kanamma Board Member, Chapter of Rheumatologists
Sriranganathan Consultant, Department of Medicine
Changi General Hospital
7(8) Dr Tan Teck Choon Board Member, Chapter of Rheumatologists
Head & Senior Consultant
Division of Rheumatology, Department of Medicine,
Khoo Teck Puat Hospital
(9) Dr Teng Gim Gee Head & Senior Consultant
Division of Rheumatology, Department of Medicine
National University Hospital
(10) Dr Bernard Thong Divisional Chairman, Medicine
Senior Consultant,
Department of Rheumatology, Allergy & Immunology
Tan Tock Seng Hospital
8PUBLISHED: MARCH 2021
Chapter of Rheumatologists
College of Physicians, Singapore
Academy of Medicine, Singapore
81 Kim Keat Road
#11-00 NKF Centre
Singapore 328836
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